Every finding on record at Westover Retirement Community

Based on observation, medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments. This affected one resident (#43) of four resident assessments reviewed. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no oral or dental issues. Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth.Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment since her admission. Interview on 11/20/25 at 10:38 A.M. with Minimum Data Set Registered Nurse (MDS RN) #70 revealed she was not certain if Resident #43 had upper natural teeth. Interview on 11/25/25 at 2:50 P.M. with Licensed Practical Nurse (LPN) #71 confirmed Resident #43 was without upper natural teeth. Interview on 11/25/25 at 3:31 P.M. with the Director of Nursing confirmed Resident #43's MDS assessment did not accurately reflect the resident's oral or dental status. This deficiency represents non-compliance investigated under Master Complaint Number 2673309.

Based on record review and staff interview, the facility failed to follow a physician order for referral services. This affected one Resident (#43) of four residents reviewed for physician orders for referral services. The facility census was 51. Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety.Review of the provider progress note dated 07/22/25 revealed Resident #43 was seen by Nurse Practitioner (NP) #105 and the resident was referred to neurology related to neuropathy. Review of the nurse's progress note dated 07/22/25 and timed 5:52 A.M. revealed a nurse's note stating Resident #43 was referred to neurology by NP #105 related to neuropathy. Resident with left foot and leg heaviness, numbness and having a hard time lifting leg and foot. Resident made aware of the referral. Review of a provider's progress note dated 07/28/25 and signed at 2:58 P.M. by NP #105 revealed Resident #43 had previously been referred to neurology for left leg and foot heaviness and numbness. Further review of the medical record for Resident #43 revealed no documentation of Resident #43 being seen by neurology.Interview on 11/25/25 at 11:06 A.M. with the Director of Nursing revealed she was unsure if Resident #43 was seen by a neurologist following the referral written by from NP #105 on 07/22/25.Interview on 11/25/25 at 1:58 P.M. with NP #105 revealed she had referred Resident #43 to neurology in July 2025 related to the resident's polyneuropathy. NP #105 was unable to verify if Resident #43 had been seen by a neurologist. This deficiency represents non-compliance investigated under Master Complaint Number 2673309 and Complaint Number 2671315.

Based on observation, medical record review, staff interview, and resident interview, the facility failed to ensure timely dental services. This affected one resident (#43) of four residents reviewed. The facility census was 51.Review of the medical record for Resident #43 revealed an admission date of 02/26/25 with diagnoses including type II diabetes mellitus with polyneuropathy and generalized anxiety. Review of the quarterly Minimum Data Set (MDS) assessments dated 06/23/25 and 09/23/25 revealed the resident had no issues with oral or dental status. Additional review of the medical record for Resident #43 revealed no documentation regarding a dental care plan or attempts to schedule a dental appointment. Observation on 11/19/25 at 1:58 P.M. of Resident #43 revealed the resident to be without natural upper teeth. Interview with Resident #43 at the time of the observation revealed the resident had lost several teeth since her admission to the facility. Resident #43 verbalized wishes to see a dentist however she has not been offered assistance in obtaining a dental appointment since her admission. Interview on 11/25/25 at 2:50 P.M. with Licensed Practical Nurse (LPN) #71 confirmed Resident #43 had no natural upper teeth. LPN #71 further confirmed Resident #43 had lost teeth during her admission and that no dental appointments had been arranged. This deficiency represents non-compliance investigated under Master Complaint Number 2673309 and Complaint Number 2671315.

Based on record review, resident and staff interviews and policy review, the facility failed to provide activities for a resident in isolation. This affected one (#22) out of one residents reviewed for activities. The facility census was 50. Findings include: Review of the medical record for Resident #22 revealed an admitted [DATE]. Diagnoses include chronic obstructive pulmonary disease, chronic diastolic (congestive) heart failure, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident with moderate cognitive impairment. Resident required set-up assistance with eating, partial assistance for oral hygiene and bathing, substantial assistance with dressing, personal hygiene, bed mobility, and transfers, and was dependent on staff assistance with toileting hygiene. Review of Resident #22's care plan, dated 05/09/24 revealed the resident has the potential for reduced social interaction and/or reduced activity participation related to dementia and anxiety. With a goal to maintain involvement in cognitive stimulation and activities of choice three to five times weekly as desired/tolerated. Interventions include assist resident to modify / rearrange daily schedule, if possible, to accommodate activities of choice, and assist/direct resident to activity location(s) as needed, encourage and assist resident to choose leisure pursuits daily as needed. Further review of Resident #22's medical record revealed there was a lack of documentation regarding involvement in activities. Interview on 10/07/24 at 11:28 A.M. with Resident #22 revealed she attends bingo for activities but nothing else. Interview with Resident #22 also revealed the activities staff does not bring any activities to her room. Interview on 10/09/24 at 9:25 A.M. with Resident Lifestyle Coordinator #267 confirmed all residents are assessed on admission for likes and dislikes and their participation in community activities. Interview on 10/09/24 at 9:41 A.M. with Resident Lifestyle Coordinator #330 confirmed when a resident attends an activity, it is documented in the progress notes. Resident Lifestyle Coordinator #330 stated one-on-one (1:1) activities in the resident room is also documented in the progress notes. Interview with Resident Lifestyle Coordinator #330 also confirmed Resident #22 doesn't like to attend a lot of activities she is given word search books at times. Resident Lifestyle Coordinator #330 confirmed there was no documentation of Resident #22 attending any activities from 08/17/24 through 10/03/24 and there was no documentation present to indicate that she refused any in room activities. Resident Lifestyle Coordinator #330 confirmed Resident #22 and her roommate had COVID-10 for a long period between 08/17/24 and 10/03/24 and activities did not go into any of the COVID-19 positive rooms. Resident Lifestyle Coordinator #330 confirmed activity packets were left outside of the COVID-19 positive rooms but she could not confirm the residents received any of the activity packets. Review of the facility Infection Control Policy dated 09/2024 revealed the purpose is to ensure the establishment and maintenance of an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Review of the policy also revealed no documentation of there being restrictions of activities when a resident is in isolation. Review of the facility Activities and Social Services Policy dated 10/01/22 revealed the purpose is to ensure the provision of an ongoing activity program that meets physical, mental, emotional, psycho-social well-being and personal interests of patients/residents at varied times of day and on weekends. Based on the patients'/residents' changes in abilities, physical and mental status, timely adjustments in programming shall be made to meet the patients'/residents' needs at all times. Activities shall be an integral component of residents' lives and should be meaningful. Activities are meaningful when they reflect a person' interests and lifestyle, are enjoyable to the person, help the person to feel useful and provide a sense of belonging. Activities will include facility-sponsored group activities, individual activities, and independent activities, and encourage both independence and interaction in the community.

Based on record review, staff, pharmacy staff and Nurse Practitioner (NP) interviews and review of medication information from Medscape, the facility failed to ensure a resident received a cardiac medication as as ordered resulting in significant medication errors. This affected one (#207) out of one residents reviewed for medication errors. The facility census was 50. Findings include: Review of the medical record for Resident #207 revealed an admitted [DATE]. Diagnoses include intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain, chronic respiratory failure with hypoxia, and acute on chronic diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) revealed no information was available due to Resident #207 being a new admission. Review of Resident #207's physician orders revealed an order dated 10/04/24 for Entresto Oral Tablet 24-26 milligrams (mg) (Sacubitril-Valsartan), give one (1) tablet by mouth two times a day related to acute on chronic diastolic (congestive) heart failure. Review of the Medication Administration Record (MAR) for October 2024 revealed an entry for Entresto Oral Tablet 24-26 mg (Sacubitril-Valsartan), give one (1) tablet by mouth two times a day related to acute on chronic diastolic (congestive) heart failure. Further review of the MAR revealed Resident #207's Entresto orally was not administered on the following dates/times: on 10/04/24 at 9:00 P.M.; on 10/05/24 at 9:00 A.M.; on 10/05/24 at 9:00 P.M.; on 10/06/24 at 9:00 A.M.; on 10/06/24 at 9:00 P.M.; on 10/07/24 at 9:00 A.M.; on 10/07/24 at 9:00 P.M.; and on 10/08/24 9:00 A.M. Further review of Resident #07's medical record revealed there was no further documentation as to why the Entresto was not administered. Interview on 10/07/24 at 2:10 with Licensed Practical Nurse (LPN) #238 confirmed Resident #207 had an order for Entresto orally two times a day related to acute on chronic diastolic (congestive) heart failure and this was ordered on admission 10/04/24. LPN #238 confirmed Resident #207 has not received the Entresto since admission. LPN #238 stated the facility has not approved the medication due to a cost issue. Interview on 10/08/24 at 2:12 P.M. with Pharmacy Technician #403 confirmed the pharmacy has not sent Entresto Oral Tablet 24-26 MG (Sacubitril-Valsartan) out for Resident #207 due to cost and the facility has not approved the cost. Pharmacy Technician #403 confirmed the facility received a fax on 10/04/24 to approve the cost for Residents #207's medication. Interview on 10/08/24 at 4:26 P.M. with NP #350 confirmed the facility did not notify the physician or NP of Resident #207 not receiving the Entresto since admission. NP #350 confirmed Resident #207's Entresto is ordered for heart failure. Review of medication information from Medscape at https://reference.medscape.com/drug/entresto-sacubitril-valsartan-1000010?_gl=1*imy860*_gcl_au*MTU0MDAzODMxNC4xNzI2NTk1Nzgz#91 revealed Entresto is used to treat heart failure. Patients taking Entresto should not start, stop, or change the dosage of the medicine without doctor's approval.

Based on interview, medical record review , and facilities policy review, the facility failed to send correct mediations home with one resident (#45) of three residents sampled for discharge. The facility census was 41. Findings include: Review of the medical record for the Resident # 45 revealed an admitted [DATE] and a discharge date of [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record revealed Resident #45 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 11/06/21 at 10:06 A.M. the Director of Nursing (DON) verified she had been informed that an agency nurse (unidentified) sent the wrong medications home with a discharged resident (unidentified). Telephone interview on 11/06/21 at 12:25 P.M. with Registered Nurse (RN) #20 stated on 10/21/21 she had review discharge instructions and medication list with Resident #45. An agency nurse (unidentified) gave medications to the family before they left, and it was later discovered that Resident #41's medications had mistakenly been given in addition to Resident #45's medications. Telephone interview on 11/06/21 at 12:37 P.M. with RN #30 stated she started work on 10/21/21 after Resident #45 had already been discharged and received a phone call from Resident #45's daughter who was confused because some of the boxes of medications did not match the names of the medications on the list she had received at discharge. RN #30 reviewed the medication list with her. One of the medications mentioned was [MEDICATION(S)], and although she found no record of it in Resident #45's chart, she told the family member that maybe the medication had been a one-time dose and advised her not to give it. RN #30 asked the family member if the Resident #45's name was on the package and she said it was. RN #30 advised the family member to give only the medications that were listed on the paperwork and to return in the morning with the medications so they could figure out hat had happened. RN #30 stated later that shift, an agency nurse (unidentified) reported to her that none of Resident #41's medications were available in the medication cart. RN #30 stated when she reviewed Resident #41's medications, she realized that his medications had been sent home with Resident #45 upon discharge. RN #30 called and informed both RN #20 and the DON, who were going to follow up with Resident #45 and family the next day. Review of policy titled, Discharge Protocol last revised 10/09/20 revealed the staff nurse or nurse manager reviewed discharge instructions and medications with the patient/representative prior to exiting the facility. This deficiency substantiates Complaint Number OH 956.

Based on record review, observation, interview, policy review, review of online resources from Centers for Disease Control (CDC) guidance, and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19, failed to ensure visitation was suspended when an employee tested positive for COVID-19, failed to ensure staff wore personal protective equipment (PPE) in the facility to prevent the potential spread of Coronavirus (COVID-19), and failed to ensure staff administered medications utilizing proper infection control practices to prevent the potential spread of infectious disease. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. Interview on 09/28/21 at 10:51, the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not initiated immediately because they did not consider the one positive employee test to be an outbreak. DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. DON verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. 2. Observation on 09/27/21 at 12:48 P.M. revealed Resident #22 in her room with two visitors on the B-wing of the facility. Observation on 09/27/21 at 12:35 P.M. revealed Resident #30's wife visiting Resident #30 in his room on the [NAME] wing. During observation of [NAME] wing on 09/27/21 at 12:00 P.M., two visitors entered Resident #2's room. Resident #2 was in quarantine status due to being a new admission and being unvaccinated. The visitor exited Resident #2's room with a lunch tray and placed it at the nursing station. The visitor entered the resident's room again with only a surgical mask in place. Interview with LPN #151 at same time verified Resident #2 had two visitors in his room and also indicated visitors should utilize appropriate PPE when visiting a resident on quarantine. During observation of the [NAME] wing on 09/29/21 at 1:00 P.M., a visitor was in Resident #147's room. Resident #147 was in quarantine status due to being new admission and being unvaccinated. The visitor was wearing only a surgical mask. Interview with Resident #147's visitor at the time of the observation revealed she had visited daily since resident was admitted on [DATE]. During observation on 09/28/21 at 11:47 A.M., a visitor was observed standing next to Resident #95 in the dining room. Concurrent interview with the visitor revealed she was Resident #95, who had recently admitted to the facility and was unaware of any restriction on visitation. During interview on 09/28/21 at 10:51 A.M., the DON stated visitation had not been suspended following LPN #82 testing positive on 09/24/21 and was not suspended at the time of the survey. Review of an email dated 09/29/21 at 9:28 A.M., the DON stated the facility had 91 visitors between 09/24/21 at 6:30 P.M. and 09/29/21 at 10:00 A.M. Review of the CMS QSO-20-39-NH-revised, dated 04/27/21, revealed, when a new case of COVID-19 among residents or staff is identified, a facility should immediately begin outbreak testing and suspend all visitation on the affected unit until at least one round of facility-wide testing was completed and no new cases were discovered. Additionally, the facility should suspend visitation on the affected units until the facility meets the criteria to discontinue outbreak testing which included 14 days of negative testing for HCP and residents. 3. Observation on 09/28/21 at 11:44 A.M. revealed Residents #28 and #95 seated at a table in the dining room. Dining Services Representative (DSR) #29 was observed wearing a surgical mask underneath his chin and delivered food to Resident #95 and briefly conversed with Residents #95 and #28. Interview on 09/28/21 at 11:46 A.M. DSR #29 verified his surgical mask was down below his chin, not covering his nose and mouth, when he delivered food to Resident #95 and conversed with Residents #95 and #28. Review of the facility's staff vaccination log revealed DSR #29 was fully vaccinated. Review of the facility policy titled, COVID-19 Preparedness and Response Plan, last updated 09/21/21 revealed employees are required to wear a mask in all patient and resident-facing areas and employees should never remove their mask in the presence of a resident. Review of the CDC guidelines titled, Infection Control Guidance, updated 09/10/21, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) revealed fully vaccinated health care personnel should wear source control (mask covering a person's mouth and nose to prevent spread of respiratory secretions when they are breathing or talking) when they are in areas of the healthcare facility where they could encounter patients (including cafeteria and common halls/corridors). 4. During observation of medication administration on 09/29/21 at 812 A.M., LPN #56 applied hand sanitizer and started to prepare medications for Resident #195. LPN #56 used her keys to open the medication cart, touched numerous areas on the cart, touched the computer and computer mouse, touched her face mask, her face shield, and her eyeglasses before she started to prepare medications, LPN #56 prepped three medications by opening the foil/paper packages and pouring them into a medicine cup. LPN #56 opened the top drawer, retrieved a bottle of multivitamins, poured a tablet in the lid, used her left thumb to secure the pill in the lid and then dumped the multivitamin in the medication cup with other medications. LPN #56 opened the drawer, retrieved a [MEDICATION(S)] 7.5 milligram (mg) package, and laid it on top of the medication cart. When LPN #56 completed preparing all medications for Resident #159, LPN #56 placed the packaged [MEDICATION(S)] in the medicine cups with other pills. LPN #56 stated she wanted to ask Resident #159 if she wanted the medication prior to opening the pill. Observation at 8:20 A.M. revealed LPN #56 entered Resident #159's room, removed the package of [MEDICATION(S)] 7.5 from the medicine cup and handed the medicine cup to Resident #159. Observation at 8:21 A.M. revealed Resident #159 took the medications in the medicine cup. During interview with LPN #56 on 09/29/21 at 8:28 A.M. verified she touched numerous items then touched Resident #159's multivitamin with her fingers. LPN #56 also verified she placed the medication package for [MEDICATION(S)] in with the other medications. This deficiency substantiates Complaint Number OH 057.

Based on record review, interview and review of the Centers for Medicare and Medicaid Services (CMS) memorandums, the facility failed to initiate immediate outbreak testing when an employee tested positive for COVID-19. This had the potential to affect all 40 residents residing in the facility. Findings include: 1. Review of the COVID-19 employee testing revealed, on 09/24/21, Licensed Practical Nurse (LPN) #82 tested positive for COVID-19 and on 09/28/21 and LPN #18 tested positive for COVID-19. Review of the nursing schedule revealed LPN #18 worked on 09/14/21 on the facility's [NAME] wing, and 09/15/21, 09/16/21, and 09/28/21 on the facility's [NAME] wing and LPN #82 worked on 09/19/21 on the facility's [NAME] wing. Review of the punch detail report for LPN #18 revealed she clocked in on 09/28/21 at 6:32 A.M. and clocked out at 10:00 A.M. During interview on 09/28/21 at 10:51 A.M., the Director of Nursing (DON) stated LPN #82 became symptomatic and tested positive for COVID-19 prior to the start of her shift on the evening of 09/24/21. The DON stated residents were not tested for COVID-19 until the evening of 09/27/21 and all staff began testing on the morning of 09/28/21 for routine testing. The DON stated resident and staff testing was not initiated immediately because they did not consider the one positive employee test to be an outbreak. The DON stated LPN #18 tested positive for COVID-19 on 09/28/21 at approximately 10:00 A.M. She verified LPN #18 worked for 3.5 hours on 09/28/21 before being tested for COVID-19. Review of the CMS QSO-20-38-NH-revised, dated 09/10/21, revealed, a new COVID-19 infection in any staff triggers an outbreak investigation. Upon identification of a single new case of COVID-19 infection in any staff or residents, testing should begin immediately. This deficiency substantiates Complaint Number OH 057.

Based on record review, interview and policy review, the facility failed to ensure the physician was notified of abnormal blood glucose and blood pressure levels. This affected one (Resident #08) of one resident reviewed for notification. The facility census was 40. Findings include: Review of the medical record of Resident #08 revealed the resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly minimum data set (MDS) assessment dated [DATE] the resident had intact cognition. Review of the physician's orders revealed orders dated 04/06/21 to check blood glucose before meals and at bedtime and call the attending practitioner and follow the Abnormal Glucose Policy if glucose is over 350 mg/dL (milligrams per deciliter) and to call the physician for systolic blood pressure (SBP) greater than 180 and/or diastolic blood pressure (DBP) greater than 90 or SBP less than 90 and/or DBP less than 40. Review of the September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M., the resident's blood sugar was 377 mg/dL. On 09/14/21 at 12:49 P.M., the resident's blood sugar was 399 mg/dL. On 09/21/21 at 5:41 P.M., the Resident's blood sugar was 443 mg/dL. On 09/21/21 at 9:51 P.M., the resident's blood sugar was 379 mg/dL. On 09/25/21 at 9:52 P.M., the Resident's blood sugar was 359 mg/dL. On 09/01/21 at 10:19 P.M., the resident's blood pressure was 126/94 mm/Hg. On 09/29/21 at 8:39 A.M., the resident's blood pressure was 110/38 mm/Hg . Review of the progress notes dated 09/01/21 through 09/30/21 revealed no evidence of physician notification of blood glucose greater than 350 mg/dL on 09/10/21, 09/14/21, 09/21/21, nor 09/25/21 and no evidence of physician notification of a DBP greater than 90 on 09/01/21 and DBP less than 40 on 09/29/21. During interview on 09/29/21 at 4:30 P.M., the Director of Nursing (DON) stated the facility policy is for the nurse to call they physician when a resident's blood sugar is greater than 450, however the physicians write orders for their own parameters. During interview on 09/30/21 at 2:30 P.M., the DON verified the chart lacked evidence of physician notification of abnormal blood pressure readings on 09/01/21 and 09/29/21 and abnormal blood sugar levels on 09/10/21, 09/15/21, 09/21/21, and 09/25/21. Review of the facility policy titled Change in Condition, updated 11/17/20, revealed the physician should immediately be notified of clinical complications and the notification should be documented in the medical record.

Based on record review, interview, and policy review, the facility failed to ensure there was ongoing communication, coordination and collaboration between the facility and the [CONDITION(S)] center. This affected one (Resident #35) of one resident who received [CONDITION(S)] in the facility. The census was 40. Findings include: Review of medical record for Resident #35 revealed an original admitted [DATE]. Additional admissions /discharges included resident was discharged with a return not anticipated on 07/21/21 and readmitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment, dated 08/20/21, revealed Resident #35 was cognitively intact, had no behaviors, did not reject care, was a one-person physical assist, required limited assistance and/or supervision for activities of daily living and received [CONDITION(S)]. Review of plan of care for Resident #35 reveled resident was dependent on renal [CONDITION(S)] related to end stage renal failure and risk for adverse effects of medications due to diuretic usage. Interventions included monitor document any signs of renal insufficiency, obtain vital signs and weight per protocol and report any significant changes and medicate as ordered per physician's orders. Review of physician orders for Resident #35 dated 07/14/21 revealed resident was ordered to receive hemodialysis on Tuesdays, Thursdays, and Saturdays at an off-site location. Review of electronic medical record and paper medical record for Resident #35 revealed no documented evidence of ongoing communication, coordination and collaboration between the nursing home and the [CONDITION(S)] staff. During interview on 09/29/21 at 4:00 P.M., the Director of Nursing (DON) stated the facility had no documented communication or collaboration notes with [CONDITION(S)] facility. During telephone interview 09/29/21 at 4:23 P.M. with [CONDITION(S)] center staff, they stated the facility called them an hour ago and requested all information from resident's admission on 07/14/21. The [CONDITION(S)] center verified there was no documented communication between them and the facility. Review of the facility policy titled [CONDITION(S)] Policy, dated 09/25/20, revealed the facility would assure resident received care and services for the provision of hemodialysis consistent with profession standards of practice including the ongoing assessment of the resident condition and monitoring for complications before and after [CONDITION(S)] treatments received and ongoing communication and collaboration with the [CONDITION(S)] facility regarding [CONDITION(S)] care and services.

Based on medical record review, staff and resident interview, review of email communication, review of facility's Covid-19 preparedness and response plan, and Centers for Disease Control (CDC) recommendations, the facility failed to complete screening of each resident at least daily for signs and symptoms of Covid-19. This affected one (#1) of three residents reviewed for Infection Control. The census was 29. Findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a quarterly minimum data set assessment of 08/26/20 revealed the resident's cognitive abilities were intact with good memory and recall. Review of the resident's current plan of care with a target completed date of 11/22/20 revealed a problem/need of being at risk for exposure and contracting Covid-19 due to communal living. The plan of care directed licensed nursing staff to conduct a Covid-19 exposure risk screener daily. Review of the electronic health record revealed for October 2020 the exposure risk screener was not completed on 16 of 31 days, and in November 2020 the exposure risk screener was not completed for 13 of 22 days through 11/22/20. Review of the resident's vitals sections for the months of October and November 2020 revealed that oxygen saturation levels were taken and recorded daily, however temperatures were not taken daily. Further review of Resident #1's medical record revealed the resident was moved to the Covid-19 unit on 11/23/20 due to testing positive for Covid-19. Interview with Resident #1 on 11/23/20 at 4:09 P.M. revealed the resident did not recall getting his temperature taken daily, stating that his temperature was taken only every so often. Interview with the Director of Nursing (DON) on 11/23/20 at 2:11 P.M., and review of email communication from the DON dated 11/23/20 at 4:49 P.M., revealed the resident should have had the daily Covid-19 exposure screening completed per his plan of care and facility policy, and verified it had not been done. The DON communicated the resident's oxygen saturation level was completed daily, and when the resident tested positive for Covid-19 he was not having symptoms. Review of the facility's COVID-19 Preparedness and Response Plan, specified that all residents of the facility were to be screened at least once daily for fever of 100.0 degrees Fahrenheit (F) or higher or repeated temperatures over 99.0 F, cough, shortness of breath, sore throat, change in sense of taste or smell, pulse oximetry less than 90% without supplement oxygen, and epidemiologic risk. Review of CDC recommendations Preparing for COVID-19 in Nursing Homes last updated 11/20/20 under Evaluate and Manage Residents with Symptoms of COVID-19 revealed to actively monitor all residents upon admission and at least daily for fever (T=100.0 F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions.

Based on observation, staff interview and policy review, the facility failed to ensure foods in the coolers and freezer were dated and stored in closed containers. The facility also failed to ensure the kitchen was clean. Additionally, the facility failed to appropriately discard items that were contaminated. This had the potential to affect all 46 residents residing in the facility whose meals were prepared in the kitchen. The facility census was 46. Findings included: 1. The initial tour of the kitchen on 02/18/20 at 10:19 [NAME]M. revealed the following areas of concern: · Floor under deep fryer had a heavy black buildup of unknown material. · The reach in cooler #2 had four hot dogs in plastic bag and a log of sliced cheese which was open and undated. · The reach in freezer #1 had four, three-gallon containers of ice cream and a bag of french fries which was opened and undated. Ice cream containers were not sealed properly with lids exposing contents to air. · Walk in freezer had an opened undated bag of french fries. There was also a plastic mat on the floor with an open weave, in between multiple weaves was a buildup of unidentified multicolored material. · Dry food storage had an opened and undated bag of pinto beans. Interview with Interim General Manager #288 verified all areas of concern on 02/18/20 at 11:30 [NAME]M. During the interview a request for cleaning schedules revealed an blank daily document. Interview with Interim General Manager #288 on 02/19/20 at 12:35 P.M. verified the process for cleaning the kitchen areas was being revamped and not all aspects of the cleaning schedule have been implemented. Further stated the facility was obtaining financial quotes from outside cleaning suppliers for deep cleaning. 2. Observation on 02/19/20 at 12:01 P.M. of Dietary Staff #72 opening reach in refrigerator and removed individual cups of fruit in a closed plastic bag and plastic silverware in a separate closed plastic bag. Dietary Staff #72 dropped the plastic bag with silverware onto the kitchen floor. Dietary Staff #72 then picked up the bag containing the plastic silverware from the floor and placed it back into the refrigerator laying it on top of the cups of individual fruit cups. Interview with Assistant Dining Services Director #289 immediately following the observation verified the silverware should have been discarded. The facility confirmed the dietary concerns had the potential to affect all 46 residents residing in the facility as all residents received their meals from the kitchen. Review of the Food Storage and Handling policy, revealed it was the policy of the dining services department to cover, label, date and store all foods in a safe and appropriate manner.

Based on medical record review, resident and staff interviews, review of a facility investigation, review of facility self reported incident (SRI) and review of facility Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source Policy, the facility failed to implement their abuse policy to ensure an allegation of staff to resident abuse was immediately reported to administration and the state agency. This affected one (#16) of three reviewed for abuse. The facility census was 48. Findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 14 day minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, and personal hygiene. Resident #16 was independent with eating, a walker and wheelchair were utilized for mobility. Review of social service late entry progress note dated 06/06/19 at 2:27 P.M. revealed a meeting was held with the family upon request with the director of nursing (DON) also present. Concerns regarding the primary nurse and medication administration positioning were discussed. The family denied plans to transfer Resident #16 to another facility and denied any further concerns. Review of social service progress note dated 06/13/19 at 1:42 P.M. revealed a conference was held with the DON, Administrator, and Resident #16's family. The family reported being satisfied with the administrator's review of the incident, felt confident necessary action was being taken, and Resident #16 was comfortable, not fearful. Interview on 06/19/19 at 12:49 P.M. with Resident #16 reported licensed practical nurse (LPN) #22 had entered her room for medication administration. The resident reported LPN #22 instructed her to take medications and Resident #16 requested the head of her bed be raised. Resident #16 reported LPN #22 then put her arm around her neck and jerked her up. The resident had both her hands behind her back to hold herself up and LPN #22 then crammed the medication in the residents mouth and gave her a drink of water. Resident #16 went to therapy and informed the therapist about the incident. Resident #16 reported feeling scared when LPN #22 jerked her up as it felt like LPN #22's elbow was in her neck, and reported rib pain afterwards. Interview on 06/20/19 at 9:28 A.M. with state tested nursing assistant (STNA) #30 reported Resident #16 informed her a nurse jerked her up out of bed and shoved medication in her mouth. STNA #30 reported Resident #16 informed her that she had already reported the incident to somebody who was going to take care of it. STNA #30 denied informing anyone about the allegation since the resident had reported someone was already taking care of it. A few days later, STNA #30 reported management called and interviewed her but was unable to recall the exact dates. Interview on 06/20/19 at 9:57 A.M. with STNA #31 reported Resident #16 informed her on 06/03/19, LPN #22 had come in to administer medications and the resident asked for the head of the bed to be raised but instead LPN #22 grabbed her by the neck and shoved the medication into her mouth. STNA #31 reported Resident #16 informed her she had reported the incident to therapy. STNA #31 reported she informed another STNA whom just brushed it off so she then reported the allegation to registered nurse manager (RNM) #90. Interview on 06/19/19 at 4:02 P.M. with certified occupational therapy assistant (COTA) #112 reported Resident #16 was upset during therapy and reported the nurse had been really rough during medication administration. The nurse wanted Resident #16 to take her medications, had sat the resident up in bed by placing her hand around the back of the resident by the resident's shoulder. Resident #16 reported holding herself up in bed with her hands and when she was unable to take the pills, due to not having any hands available, the nurse shoved the pills in her mouth. Resident #16 reported she had told multiple staff members but not necessarily nursing staff. COTA #112 reported she asked Resident #16 if she wanted to talk to the nursing supervisor and she replied yes. COTA #112 informed RNM #90 whom came and talked to the resident. COTA #112 reported being present during the conversation and Resident #16 reported to RNM #90 the same information she had reported earlier. COTA #112 was unable to recall the exact date but felt the resident reported the incident the day after it had occurred. Interview on 06/20/19 at 10:52 A.M. with LPN #22 reported she was informed by RNM #90 that the DON had instructed LPN #22 was no longer to provide care to Resident #16, per the resident request. About a week later, management requested LPN #22 provide a statement. LPN #22 reported no further information was requested, just to explain the method used to administer medications. Management informed LPN #22, everything was okay and LPN #22 continued to work. About a week later, the DON approached LPN #22 at the end of her shift, and informed LPN #22 she was being removed from the schedule pending an investigation as to the reasons Resident #16 didn't want LPN #22 in her room. LPN #22 denied treating Resident #16 in an aggressive manner and reported the resident never liked to get out of bed and she just encouraged Resident #16 to sit upright, on the side of the bed to take medications for safety reasons. LPN #22 denied Resident #16 requested the head of the bed to be raised and reported it was better for residents to sit on the side of the bed in case they dropped a pill as it would be more visible. Interview on 06/20/19 at 11:26 A.M. with RNM #90 reported on 06/03/19 COTA #112 informed her Resident #16 wanted to talk to her. Resident #16 reported LPN #22 had put her hand behind her neck while placing another hand on her leg, twisted the resident around quickly, and gave her medication. Resident #16 reported it was really fast, not gentle, and Resident #16 didn't want LPN #22 in her room anymore. RNM #90 denied any other employees informing her about the allegation. RNM #90 reported she informed the DON whom reported to remove LPN #22 from caring for the resident. Interview on 06/20/19 at 12:00 P.M. with the DON reported Resident #16's family called RNM #90 on 06/03/19 and reported they did not want LPN #22 providing care to the resident. RNM #90 informed the DON and Resident #16 was removed from LPN #22's assignment. The DON reported she did not inquire into the reason for the request. A meeting was held with Resident #16's family on 06/06/19 and when they explained the incident, the DON reported she just took it as LPN #22 assisted the resident up, to sit on the edge of the bed. The DON reported she was aware LPN #22 preferred all residents to sit on the side of the bed when they took medications. The DON did not feel the reported incident was an allegation of abuse and reported the family felt comfortable since LPN #22 was no longer providing care to the resident. The DON reported she was not informed or aware Resident #16 alleged LPN #22 jerked her out of bed until the investigation was initiated, after another meeting was conducted with a different family member on 06/12/19. Review of facility investigation report dated 06/12/19 revealed a complaint dated of 06/03/19 and abuse allegation on 06/12/19. Nature of the complaint included on 06/03/19, Resident #16 informed COTA #112, LPN #22 jerked her out of bed to sit her up. Upon being asked, Resident #16 requested to talk to the RNM. RNM #90 was informed and interviewed the resident on 06/03/19. Resident #16 informed RNM #90 that LPN #22 put her arm around the back of her neck with a hand on her leg to sit her up and she didn't want LPN #22 in her room again. LPN #22 was removed from providing care to Resident #16 and RNM #90 emailed the DON and informed the DON that LPN #22 had been removed from providing care to the resident. On 06/12/19, Resident #16's family requested to speak with management and informed the Administrator and DON that LPN #22 forcefully sat Resident #16 up on the side of the bed, shoved medication in the residents mouth, and choked the resident. An investigation was then initiated into the allegation of abuse. Review of facility SRI dated 06/12/19 revealed an allegation of neglect was discovered on 06/12/19. Resident #16 reported LPN #22 shoved medication in her mouth and sat her up on the edge of the bed. Summary of incident revealed on 06/03/19 Resident #16 informed COTA #112, LPN #22 jerked her out of bed to sit her up. Resident #16 reported she wanted to talk to a nurse manager. RNM #90 spoke to Resident #16 on 06/03/19. The resident reported she didn't want LPN #22 in her room anymore because she was mean, put her arm around the back of the residents neck and on her leg to sit her up. Resident #16 called her family whom called and reported they did not want LPN #22 providing care to the resident. RNM #90 removed LPN #22 from caring for the resident and emailed the DON that LPN #22 had been removed from providing care to Resident #16. The DON spoke to Resident #16 whom denied feeling unsafe and just reported being in pain. On 06/12/19, Resident #16's family came to the facility and requested to speak with the Administrator. A care conference was conducted and the family whom reported LPN #22 forcefully sat Resident #16 on the side of the bed, shoved medications in her mouth, and choked the resident. Resident #16 complained of back and rib pain after the incident. It was reported Resident #16 felt LPN #22 abused her. The new information prompted the initiation of the facility abuse policy. Based on the facility's investigation, the allegation was unsubstantiated as evidence was inconclusive and abuse was not suspected. Review of facility Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source last approved 10/31/18 revealed all allegations of abuse would be investigated. Verbal allegations reported to any member of the administrative or supervisory nursing staff would be taken seriously. Supervisors would be attentive to resident complaints of mistreatment, and would investigate and report all allegations of abuse to the administrator. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials including the Ohio Department of Health. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on medical record review, resident and staff interviews, review of a facility investigation, review of facility self reported incident (SRI) and review of facility Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source Policy, the facility failed to ensure an allegation of staff to resident abuse was immediately reported to administration and to the state agency. This affected one (#16) of three reviewed for abuse. The facility census was 48. Findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 14 day minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, and personal hygiene. Resident #16 was independent with eating, a walker and wheelchair were utilized for mobility. Review of social service late entry progress note dated 06/06/19 at 2:27 P.M. revealed a meeting was held with the family upon request with the director of nursing (DON) also present. Concerns regarding the primary nurse and medication administration positioning were discussed. The family denied plans to transfer Resident #16 to another facility and denied any further concerns. Review of social service progress note dated 06/13/19 at 1:42 P.M. revealed a conference was held with the DON, Administrator, and Resident #16's family. The family reported being satisfied with the administrator's review of the incident, felt confident necessary action was being taken, and Resident #16 was comfortable, not fearful. Interview on 06/19/19 at 12:49 P.M. with Resident #16 reported licensed practical nurse (LPN) #22 had entered her room for medication administration. The resident reported LPN #22 instructed her to take medications and Resident #16 requested the head of her bed be raised. Resident #16 reported LPN #22 then put her arm around her neck and jerked her up. The resident had both her hands behind her back to hold herself up and LPN #22 then crammed the medication in the residents mouth and gave her a drink of water. Resident #16 went to therapy and informed the therapist about the incident. Resident #16 reported feeling scared when LPN #22 jerked her up as it felt like LPN #22's elbow was in her neck, and reported rib pain afterwards. Interview on 06/20/19 at 9:28 A.M. with state tested nursing assistant (STNA) #30 reported Resident #16 informed her a nurse jerked her up out of bed and shoved medication in her mouth. STNA #30 reported Resident #16 informed her that she had already reported the incident to somebody who was going to take care of it. STNA #30 denied informing anyone about the allegation since the resident had reported someone was already taking care of it. A few days later, STNA #30 reported management called and interviewed her but was unable to recall the exact dates. Interview on 06/20/19 at 9:57 A.M. with STNA #31 reported Resident #16 informed her on 06/03/19, LPN #22 had come in to administer medications and the resident asked for the head of the bed to be raised but instead LPN #22 grabbed her by the neck and shoved the medication into her mouth. STNA #31 reported Resident #16 informed her she had reported the incident to therapy. STNA #31 reported she informed another STNA whom just brushed it off so she then reported the allegation to registered nurse manager (RNM) #90. Interview on 06/19/19 at 4:02 P.M. with certified occupational therapy assistant (COTA) #112 reported Resident #16 was upset during therapy and reported the nurse had been really rough during medication administration. The nurse wanted Resident #16 to take her medications, had sat the resident up in bed by placing her hand around the back of the resident by the resident's shoulder. Resident #16 reported holding herself up in bed with her hands and when she was unable to take the pills, due to not having any hands available, the nurse shoved the pills in her mouth. Resident #16 reported she had told multiple staff members but not necessarily nursing staff. COTA #112 reported she asked Resident #16 if she wanted to talk to the nursing supervisor and she replied yes. COTA #112 informed RNM #90 whom came and talked to the resident. COTA #112 reported being present during the conversation and Resident #16 reported to RNM #90 the same information she had reported earlier. COTA #112 was unable to recall the exact date but felt the resident reported the incident the day after it had occurred. Interview on 06/20/19 at 10:52 A.M. with LPN #22 reported she was informed by RNM #90 that the DON had instructed LPN #22 was no longer to provide care to Resident #16, per the resident request. About a week later, management requested LPN #22 provide a statement. LPN #22 reported no further information was requested, just to explain the method used to administer medications. Management informed LPN #22, everything was okay and LPN #22 continued to work. About a week later, the DON approached LPN #22 at the end of her shift, and informed LPN #22 she was being removed from the schedule pending an investigation as to the reasons Resident #16 didn't want LPN #22 in her room. LPN #22 denied treating Resident #16 in an aggressive manner and reported the resident never liked to get out of bed and she just encouraged Resident #16 to sit upright, on the side of the bed to take medications for safety reasons. LPN #22 denied Resident #16 requested the head of the bed to be raised and reported it was better for residents to sit on the side of the bed in case they dropped a pill as it would be more visible. Interview on 06/20/19 at 11:26 A.M. with RNM #90 reported on 06/03/19 COTA #112 informed her Resident #16 wanted to talk to her. Resident #16 reported LPN #22 had put her hand behind her neck while placing another hand on her leg, twisted the resident around quickly, and gave her medication. Resident #16 reported it was really fast, not gentle, and Resident #16 didn't want LPN #22 in her room anymore. RNM #90 denied any other employees informing her about the allegation. RNM #90 reported she informed the DON whom reported to remove LPN #22 from caring for the resident. Interview on 06/20/19 at 12:00 P.M. with the DON reported Resident #16's family called RNM #90 on 06/03/19 and reported they did not want LPN #22 providing care to the resident. RNM #90 informed the DON and Resident #16 was removed from LPN #22's assignment. The DON reported she did not inquire into the reason for the request. A meeting was held with Resident #16's family on 06/06/19 and when they explained the incident, the DON reported she just took it as LPN #22 assisted the resident up, to sit on the edge of the bed. The DON reported she was aware LPN #22 preferred all residents to sit on the side of the bed when they took medications. The DON did not feel the reported incident was an allegation of abuse and reported the family felt comfortable since LPN #22 was no longer providing care to the resident. The DON reported she was not informed or aware Resident #16 alleged LPN #22 jerked her out of bed until the investigation was initiated, after another meeting was conducted with a different family member on 06/12/19. Review of facility investigation report dated 06/12/19 revealed a complaint dated of 06/03/19 and abuse allegation on 06/12/19. Nature of the complaint included on 06/03/19, Resident #16 informed COTA #112, LPN #22 jerked her out of bed to sit her up. Upon being asked, Resident #16 requested to talk to the RNM. RNM #90 was informed and interviewed the resident on 06/03/19. Resident #16 informed RNM #90 that LPN #22 put her arm around the back of her neck with a hand on her leg to sit her up and she didn't want LPN #22 in her room again. LPN #22 was removed from providing care to Resident #16 and RNM #90 emailed the DON and informed the DON that LPN #22 had been removed from providing care to the resident. On 06/12/19, Resident #16's family requested to speak with management and informed the Administrator and DON that LPN #22 forcefully sat Resident #16 up on the side of the bed, shoved medication in the residents mouth, and choked the resident. An investigation was then initiated into the allegation of abuse. Review of facility SRI dated 06/12/19 revealed an allegation of neglect was discovered on 06/12/19. Resident #16 reported LPN #22 shoved medication in her mouth and sat her up on the edge of the bed. Summary of incident revealed on 06/03/19 Resident #16 informed COTA #112, LPN #22 jerked her out of bed to sit her up. Resident #16 reported she wanted to talk to a nurse manager. RNM #90 spoke to Resident #16 on 06/03/19. The resident reported she didn't want LPN #22 in her room anymore because she was mean, put her arm around the back of the residents neck and on her leg to sit her up. Resident #16 called her family whom called and reported they did not want LPN #22 providing care to the resident. RNM #90 removed LPN #22 from caring for the resident and emailed the DON that LPN #22 had been removed from providing care to Resident #16. The DON spoke to Resident #16 whom denied feeling unsafe and just reported being in pain. On 06/12/19, Resident #16's family came to the facility and requested to speak with the Administrator. A care conference was conducted and the family whom reported LPN #22 forcefully sat Resident #16 on the side of the bed, shoved medications in her mouth, and choked the resident. Resident #16 complained of back and rib pain after the incident. It was reported Resident #16 felt LPN #22 abused her. The new information prompted the initiation of the facility abuse policy. Based on the facility's investigation, the allegation was unsubstantiated as evidence was inconclusive and abuse was not suspected. Review of facility Abuse, Neglect, Exploitation, Misappropriation, and Injuries of Unknown Source last approved 10/31/18 revealed all allegations of abuse would be investigated. Verbal allegations reported to any member of the administrative or supervisory nursing staff would be taken seriously. Supervisors would be attentive to resident complaints of mistreatment, and would investigate and report all allegations of abuse to the administrator. All alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials including the Ohio Department of Health. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on medical record review, observations, staff and resident interview, review of a call light/pendent report and policy review, the facility failed to ensure a resident was timely assessed and interventions implemented for complaints of pain. This affected one (#16) of three reviewed for care during the survey. The facility census was 48. Findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 14 day minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making, extensive assistance was required with bed mobility, transfers, toileting, and personal hygiene. Resident #16 was independent with eating, a walker and wheelchair were utilized for mobility. Review of physician orders [REDACTED]. Review of care plan initiated 05/27/19 revealed Resident #16 had a potential for an alteration in comfort related to breathing difficulties due to [MEDICAL CONDITION], constipation, limited mobility, and recent surgery. Interventions included assess for cause of pain or discomfort and attempt to eliminate if possible; evaluate pain per facility pain policy and as needed; medicate for pain and discomfort and ordered; offer gentle back rub as needed; and reposition for comfort. Interview with Resident #16 on 06/19/19 at 12:54 P.M. reported she had pushed her call pendant three times over the last 40 minutes, for pain medication, and nobody had responded. Observation revealed the resident again pushed the pendant button. At 1:04 P.M., two state tested nursing assistants (STNA's) responded and Resident #16 informed them she needed pain medication. Continuous observation on 06/19/19 from 1:04 P.M. to 2:11 P.M. revealed Resident #16 repositioned self periodically throughout the interview in her wheelchair but was able to participate in conversation without distress. No nursing staff had responded to assess or address Resident #16's pain. At 2:17 P.M., therapy arrived and transported Resident #16 to the therapy room in a wheelchair. Interview on 06/19/19 at 2:16 P.M. with licensed practical nurse (LPN) #24 reported the STNA's informed her about Resident #16's request for pain medication but the resident had received pain medication at 11:00 A.M. and wasn't able to receive more for four hours. LPN #24 reported Resident #16 didn't have anything else ordered for pain and the resident would sometimes forget she had already received pain medication. LPN #24 acknowledged other interventions could be attempted but reported Resident #16 seldom complained of pain between doses of pain medication. LPN #24 acknowledged she had not assessed Resident #16's pain, attempted care planned interventions, or told the resident her pain medication wasn't due until 3:00 P.M. LPN #24 had informed the STNA's, Resident #16 was not due for more pain medication until 3:00 P.M., as she was in the middle of something, and reported the STNA's should have informed the resident. Interview on 06/19/19 at 2:49 P.M. with the director of nursing (DON) reported Resident #16 was assessed, was participating in therapy without signs of distress, and reported she would wait until next pain pill was scheduled for administration. The DON provided a record of Resident #16's call light/pendant activation times and confirmed it took staff 36 minutes to respond to the pendant/call light. The DON reported the facility did not have a policy for call lights but the expectation was response time would be under ten minutes. When a pendant/call light was activated it would register on phones carried by the state tested nursing assistants (STNA's) and on the call monitor located at the nursing station. If the assigned STNA was unable to respond timely, another staff member would be aware and should respond to the residents need for assistance. Review of Resident #16 call light/pendant report revealed Resident #16 activated her pendant on 06/19/19 at 12:29 P.M. and staff responded and turned it off at 1:05 P.M. Interview on 06/19/19 at 4:02 P.M. with certified occupational therapy assistant (COTA) #112 reported Resident #16 frequently complained of pain and will decline therapy. The resident always identified pain at a level seven on a scale of zero, representing no pain, to a level ten, representing severe pain, even after she has reported relief and benefits from ice or pain medication. COTA #112 reported the nurse spoke to Resident #16 during therapy and the resident reported the ability to wait until next pain medication was due. Interview on 06/19/19 at 3:40 P.M. with Resident #16 reported therapy applied ice, she received pain medication at 3:00 P.M., and was now comfortable without any pain. Review of Pain Assessment Policy dated 03/18/19 revealed staff nurses would complete a pain assessment once a shift and as needed. Review of Quality of Care Policy last dated (MONTH) (YEAR) revealed the facility must ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on observation, staff interview, and review of Storage of Medications Policy, the facility failed to ensure all medications were stored in a secure manner. This affected three (#39, #41, and #47) out of 17 residents medications who were being stored on the(NAME)hall. Facility census was 48. Findings include: Observation on 06/19/19 at 3:46 P.M. of the open nursing station on the(NAME)hall revealed an unlocked cabinet next to the corridor to therapy which contained liquid medications including one bottle of lacteals ten grams (G) per 15 milliliters (ml) for Resident #47, one nine ounce bottle and one 11 ounce bottle of potassium chloride ten percent solution for Resident #41, 16 ounce bottle of [MEDICATION NAME] oral suspension and a four ounces bottle of [MEDICATION NAME] cough syrup for Resident #39. The unlocked cabinet also contained the following unopened stock medications: [REDACTED]. There weren't any visible staff members in the vicinity of the unlocked medication cabinet. Interview on 06/19/19 at 3:54 P.M. with the Director of Nursing (DON), whom arrived at the(NAME)hall nursing station verified the unlocked liquid medication cabinet and reported the cabinet should have been locked. The DON denied any independently mobile cognitively impaired residents resided on(NAME)hall. The DON confirmed Resident #39, #41 and #47's medications were being stored unsecured and the other medications were stock medications and not assigned to a particular resident. Review of Storage of Medications Policy dated 07/25/18 revealed drugs shall be stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding. All medications and other drugs, including treatment items, shall be stored in a locked cabinet or room, inaccessible to residents and visitors. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

Based on review of the facility's Legionella prevention policy and staff interview, the facility failed to complete water temperature checks. This had the potential to affect all the residents of the facility. The facility census was 51. Findings include: Review of the facility's policy titled Legionella Prevention & Intervention dated 06/01/18 revealed that monthly or more frequent checks would be completed to ensure cold water was released below 68 degrees Fahrenheit (F) and hot water was heated to greater than 122 F before mixing valves cool it to below 120 F. The facility was unable to provide documentation of cold or hot water checks per their Legionella Prevention & Intervention policy. Maintenance Director #200 was interviewed on 12/28/18 at 12:52 P.M. and confirmed water temperature checks were not completed per the facility's Legionella Prevention & Intervention policy.

Based on medical record review and staff interview the facility failed to ensure as needed (PRN) [MEDICAL CONDITION] medications had an ordered duration of use. This affected four Residents (#4, #27, #32 and #43) of five residents reviewed for unnecessary medications. The facility also failed to attempt non-pharmacological interventions before the administration of a PRN [MEDICAL CONDITION] medication. This affected one Resident (#32) of five residents reviewed for unnecessary medications. The facility identified 38 residents currently receiving [MEDICAL CONDITION] medications. The facility census was 51. Findings include: 1. Review of Resident #27's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #27 was assessed as being cognitively intact in an Minimum Data Set ((MDS) dated [DATE]. Review of physician orders [REDACTED]. Further review of the [MEDICATION NAME] order revealed there was no duration of use given. End date was documented as indefinite. Review of a facility document titled Consultant Pharmacist-Interim Reviews dated 10/06/18 revealed a request was made to the prescribing physician to provide documentation of a rationale for continuing PRN [MEDICATION NAME] beyond the 14 days. This document was signed by the physician 10/08/18 with the note the they would re-evaluate. Review of a facility document titled Consultant Pharmacist-Interim Reviews dated 12/17/18 revealed a request was made to the prescribing physician to provide documentation of a rationale for continuing PRN [MEDICATION NAME] beyond 14 days. Resident #27 was documented as being on [MEDICATION NAME] 15 mg since 10/05/18. This document was signed by the physician on 12/24/18 with a new order to decrease [MEDICATION NAME] to 10 mg at bedtime. No duration of use for the [MEDICATION NAME] was given. Review of medication treatment records (MAR's) for 10/01/18 through 12/28/18 revealed Resident #27 received the [MEDICATION NAME] a total of eight times. The Director of Nursing (DON) confirmed during an interview on 12/28/18 at 12:08 P.M. that Resident #27's order for [MEDICATION NAME] dated 10/05/18 did not have an ordered duration of use. The DON also confirmed that Resident #27 received [MEDICATION NAME] 15 mg PRN and that the physician had ordered a decrease the [MEDICATION NAME] to 10 mg on 12/24/18. 2. Medical record review revealed Resident #32 was admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. Review of the 14 day MDS revealed the resident had severe cognitive impairment. Review of physicians orders dated 12/13/18 revealed an order for [REDACTED]. Review of the MAR for 12/2018 revealed Resident #32 had received six doses of the [MEDICATION NAME]. Review of the Treatment Administration Record (TAR) for 12/2018 revealed Resident #32 had no non-pharmacological interventions or behavioral monitoring in place for the [MEDICATION NAME]. Interview on 12/28/18 at 11:31 A.M. with Licensed Practical Nurse (LPN) #230 verified there was no end date for the PRN [MEDICATION NAME] and there were no non-pharmacological or behavioral monitoring interventions for Resident #32's [MEDICATION NAME]. 3. Resident # 43 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required two-person extensive to total assistance for activities of daily living and only required limited assistance for eating. Review of the current physician's orders [REDACTED]. The order posted in the electronic medical record revealed the duration of the PRN medication was indefinite Review of the 12/2018 MAR indicated [REDACTED]. Interview on 12/28/18 at 11:13 A.M., LPN #230 verified the duration for the PRN [MEDICATION NAME] order was listed as indefinite in the physician's orders [REDACTED]. LPN #230 verified the medical record contained no physician documentation of a rationale or time duration to continue the medication beyond 14 days. 4. Record review of Resident #4's medical record, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the MDS dated [DATE], revealed Resident #4 had no cognitive impairments. Review of physician order [REDACTED]. The physician orders [REDACTED]. Further review, revealed the orders had indefinite listed in the end date. The orders were discontinued on 12/14/18 when new orders were created. Review of a facility document titled Consultant Pharmacist-Interim Reviews dated 10/17/18, revealed Resident # 4's medications were reviewed by a pharmacist. The report indicated [MEDICATION NAME] was the only medication with recommendations. Review of the 10/2018 MAR indicated [REDACTED]. Review of a facility document titled Consultant Pharmacist-Interim Reviews dated 11/15/18, revealed Resident #4's name wasn't on the report for any medication recommendations. Review of the 11/2018 MAR, revealed Resident #4, received 55 doses of the PRN [MEDICATION NAME]. Review of the 12/2018 MAR, revealed Resident #4, received 20 doses of the PRN [MEDICATION NAME]. During staff interview on 12/28/18 at 3:15 P.M., the DON verified the physician orders [REDACTED]. She further verified the [MEDICATION NAME] orders were to give one tablet by mouth three times a day related to generalized anxiety disorder and give one tablet by mouth every four hours as needed for anxiety disorder. The DON verified the PRN [MEDICATION NAME] orders did not have an ordered duration of use and was listed as indefinite in the end date. The DON verified the orders were active from 10/12/18 until the discontinuation on 12/14/18 and Resident #4 received a total of 110 doses of the PRN [MEDICATION NAME].

Based on record review and staff interview, the facility failed to provide timely delivery of required resident rights notices when skilled services were discontinued. This affected two (#32 and #44) of three residents reviewed for beneficiary liability protection notices. The facility census was 51. Findings include: 1. Review of the medical record revealed Resident #32 was admitted [DATE] and continued to reside in the facility after skilled services were discontinued. The beneficiary notices provided by the facility indicated the resident's Medicare Part A skilled services ended 11/21/18. The Notice of Medicare Non-Coverage (NOMNC) letter and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were signed and dated by the resident's representative on 11/21/18, indicating the facility provided no advanced notification of skilled services being discontinued. 2. Review of the medical record revealed Resident #44 was admitted [DATE] and continued to reside in the facility after skilled services were discontinued. The beneficiary notices provided by the facility indicated the resident's Medicare Part A skilled services ended 10/16/18. The Notice of Medicare Non-Coverage (NOMNC) letter and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) were signed and dated by the resident's representative on 10/16/18, indicating the facility provided no advanced notification of skilled services being discontinued. Interview on 12/28/18 at 1:59 P.M., Social Services Coordinator (SSC) #220 verified the residents and their representatives did not receive written notice of skilled services being discontinued before the last covered day, and that the NOMNC and SNFABN letters were signed and dated by the residents' representatives on the same day the skilled services were discontinued.

Based on closed medical record review, staff interview, and facility policy, the facility failed to provide residents with written bed-hold notices when hospitalized . This affected one (#38) of one resident reviewed for hospitalization . The facility census was 51. Findings include: Resident # 38 admitted [DATE]. [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. Review of the medical record revealed the resident was emergently hospitalized [DATE] for acute [MEDICAL CONDITION]. The medical record contained no evidence that the facility provided the resident or his/her representative with written bed hold information when hospitalized . Interview on 12/28/18 at 3:16 P.M., the Administrator verified the medical record contained no evidence that written bed hold information was provided to the resident or representative when the resident was hospitalized . Review of the facility policy titled, Bed Hold Policy dated 09/23/17 revealed Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident resident representative.